Venous Sinus Stenosis Treatment in Pediatric Idiopathic Intracranial Hypertension: Illustrative Case and Literature Review

IntroductionAlthough venous sinus stenting (VSS) has emerged as a promising treatment option for patients with idiopathic intracranial hypertension (IIH) and associated venous sinus stenosis, there is considerable ambiguity regarding patient selection criteria, treatment protocols, and management strategies.MethodsAn extensive literature review was performed to identify all reports of VSS in patients with IIH using PubMed. Recommendations for the selection and treatment of patients with IIH with VSS are outlined as determined based on author opinion from supporting studies. Due to the lack of randomized trials and few published prospective studies, standard grading scales for recommendations and level of evidence are not fully applicable and therefore a revised grading scale has been provided for recommendations.ResultsThe literature review identified a total of eight systematic reviews or meta-analyses and 29 published patient series on VSS. Recommendations for patient selection for diagnostic catheter angiography, angiography procedural considerations, stenting procedural considerations, and retreatment are provided based on the literature. Recommendations that were considered strong included: performance of venous sinus manometry to assess candidacy for treatment prior to stenting; administration of antiplatelet agents prior to stenting and for a follow-up period of at least 3–6 months; performance of post-stenting manometry to confirm resolution of pressure gradient; and performance of repeat angiography and manometry on patients with recurrence of symptoms after resolution with stenting to evaluate for recurrent stenosis.ConclusionVSS for patients with IIH with venous sinus stenosis is now an established and effective treatment option. These recommendations have been provided, based on a summative review of the available published literature, to assist in standardizing care for patients with IIH undergoing VSS.

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Intracranial Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A Case Report and Review of the Literature

Brain Sciences ◽

10.3390/brainsci11030382 ◽

2021 ◽

Vol 11 (3) ◽

pp. 382

Author(s):

Dinesh Ramanathan ◽

Zachary D. Travis ◽

Emmanuel Omosor ◽

Taylor Wilson ◽

Nikhil Sahasrabudhe ◽

...

Keyword(s):

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Vision Loss ◽

Transverse Sinus ◽

Venous Sinus ◽

Subdural Hygroma ◽

Presenting Symptoms ◽

Minimal Improvement ◽

Sinus Stenosis ◽

Work Up

We describe a case of severe headaches, double vision, and progressive vision loss secondary to a ruptured intracranial cyst (IAC) in a 31-year-old woman with no relevant past medical history. The case is peculiar because drainage of the subdural hygroma led to a minimal improvement in vision with persistent elevated intracranial pressure (ICP). Further exploration revealed transverse sinus stenosis necessitating stenting. Evaluation post-stenting showed marked reduction of ICP and improvement in symptoms. This report underscores the importance of comprehensive work-up and suspicion of multiple underlying etiologies that may be crucial to complete resolution of presenting symptoms in some cases. We provide an overview of the clinical indications and evidence for venous sinus stenting in treating idiopathic intracranial hypertension (IIH).

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Abstract 1122‐000232: The Importance of Performing Venous Pressure Measurements Following Venous Sinus Stenting for Idiopathic Intracranial Hypertension

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000232 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Yazan Radaideh

Keyword(s):

Pressure Gradient ◽

Intracranial Hypertension ◽

Stent Placement ◽

Idiopathic Intracranial Hypertension ◽

Venous Pressure ◽

Sigmoid Sinus ◽

Venous Sinus ◽

Pressure Measurements ◽

Sinus Stenosis ◽

The Right

Introduction : Although venous sinus stenting is an established treatment for medically refractory idiopathic intracranial hypertension, a subset of patients shows little or no improvement of symptoms after stenting. While this could be related to a number of factors, failure to sufficiently address the pressure gradient is one that can be recognized during the treatment procedure. We describe two patients who had a persistent venous pressure gradient after stent placement. Once identified, a second stent was placed with subsequent resolution of the pressure gradient. Methods : This retrospective chart review identified patients at a single institution who underwent venous sinus stenting and required immediate placement of a second venous sinus stent for a persistent pressure gradient. Results : Two patients with refractory idiopathic intracranial hypertension underwent cerebral angiography with venous manometry. In the first patient, unilateral venous sinus stenosis was present with a maximum pressure of 50 mmHg, which only decreased to 30 mmHg after placement of a right transverse‐sigmoid sinus stent. Subsequent manometry revealed a persistent gradient between the superior sagittal sinus and the right transverse sinus, which resolved after placement of a second stent in this location. In the second patient, bilateral stenosis was observed at the transverse‐sigmoid sinus junction; the maximum venous pressure was 40 mmHg, and a gradient of 30 mmHg was measured at the right transverse‐sigmoid junction, where a venous sinus stent was placed. Venous sinus pressure measurements performed immediately after the stent placement demonstrated a persistent pressure gradient of 20 mmHg in the contralateral transverse‐sigmoid sinus junction, which resolved after contralateral stent placement. Both patients showed sustained improvement in their symptoms at 1 year follow up. Conclusions : In some patients with idiopathic intracranial hypertension and venous sinus stenosis, a single stent may not sufficiently reduce the pressure gradient. A second stent may be required; however, this is only detectable with post‐stent pressure measurements. Performing manometry after stent placement should be routinely performed in order to detect persistent venous pressure gradient.

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Transverse venous sinus stenosis in idiopathic intracranial hypertension: a prospective pilot study

Canadian Journal of Ophthalmology ◽

10.1016/j.jcjo.2020.05.008 ◽

2020 ◽

Vol 55 (5) ◽

pp. 401-405

Author(s):

Wesley Chan ◽

A. Laine Green ◽

Anuradha Mishra ◽

Charles Maxner ◽

Jai J.S. Shankar

Keyword(s):

Pilot Study ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Venous Sinus ◽

Prospective Pilot Study ◽

Sinus Stenosis

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O-031 Role of resistivity index analysis in the prediction of hemodynamically significant venous sinus stenosis in patients with idiopathic intracranial hypertension

10.1136/neurintsurg-2019-snis.31 ◽

2019 ◽

Author(s):

M Mohammaden ◽

M Rizwan Husain ◽

D Brunozzi ◽

G Atwal ◽

F Charbel ◽

...

Keyword(s):

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Venous Sinus ◽

Resistivity Index ◽

Index Analysis ◽

Sinus Stenosis

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Venous sinus stenting in patients without idiopathic intracranial hypertension

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012405 ◽

2016 ◽

Vol 9 (5) ◽

pp. 512-515 ◽

Cited By ~ 10

Author(s):

Michael R Levitt ◽

Felipe C Albuquerque ◽

Bradley A Gross ◽

Karam Moon ◽

Ashutosh P Jadhav ◽

...

Keyword(s):

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Sinus Thrombosis ◽

Venous Sinus ◽

Congenital Hydrocephalus ◽

Pulsatile Tinnitus ◽

Venous Sinus Thrombosis ◽

Sinus Stenosis ◽

Dural Venous Sinus

BackgroundVenous sinus stenting is an effective treatment for patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis.ObjectiveTo determine the usefulness of venous sinus stenting in the treatment of patients with symptomatic venous sinus stenosis without a diagnosis of IIH.MethodsWe performed a retrospective review of a prospective multicenter database of patients undergoing venous sinus stenting between January 2008 and February 2016. Patients with acute dural venous sinus thrombosis, arteriovenous fistula or arteriovenous malformation, or IIH were excluded. Clinical, radiological, and ophthalmological information was recorded.ResultsNine patients met the inclusion criteria and underwent venous sinus stenting for symptomatic dural venous sinus stenosis. Reasons for treatment included isolated unilateral pulsatile tinnitus (n=1), congenital hydrocephalus (n=2), unilateral pulsatile tinnitus following prior venous sinus thrombosis (n=1), acquired hydrocephalus following dural sinus thrombosis (n=2), meningitis (n=2) and tumor invasion into the dural venous sinus (n=1). Six patients underwent lumbar puncture or shunt tap, and all of these patients had elevated intracranial pressure. All stenoses were located in the transverse sinus, transverse–sigmoid junction and/or jugular bulb, and all were treated with self-expanding bare-metal stents. At follow-up, clinical symptoms had resolved in all but two patients, both of whom had congenital hydrocephalus and pre-existing shunts. There was no significant in-stent stenosis, and patients with ophthalmological follow-up demonstrated improvement of papilledema.ConclusionsDural venous sinus stenting may be an effective treatment for patients with symptomatic venous sinus stenosis without IIH in carefully selected cases, but may not be effective in resolving the symptoms of congenital hydrocephalus.

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Retrograde 3D rotational venography (3DRV) for venous sinus stent placement in idiopathic intracranial hypertension

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013533 ◽

2017 ◽

Vol 10 (8) ◽

pp. 777-779 ◽

Cited By ~ 1

Author(s):

Christopher C Young ◽

Ryan P Morton ◽

Basavaraj V Ghodke ◽

Michael R Levitt

Keyword(s):

Intracranial Hypertension ◽

Stent Placement ◽

Idiopathic Intracranial Hypertension ◽

Three Dimensional ◽

Venous Sinus ◽

Flat Panel ◽

Venous Sinuses ◽

Contrast Enhanced ◽

Sinus Stenosis ◽

Dural Venous Sinus

BackgroundDural venous sinus stenting has emerged as an effective and durable treatment for idiopathic intracranial hypertension (IIH). Improved visualization of the venous sinuses can improve stent placement.MethodsWe present two cases of IIH treated with venous sinus stenting in which retrograde three-dimensional rotational venography (3DRV) provided superior anatomical details of the venous sinuses for optimal sizing and positioning of stent.ResultsComparison of pre-stent 3DRV with post-stent contrast-enhanced flat panel detector CT allowed confirmation of stent placement and the result of stenosis dilation.ConclusionThis 3DRV technique provides precise visualization of venous sinus stenosis prior to stenting without the need for arterial cerebral angiography during the treatment course.

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